Provider Demographics
NPI:1790880904
Name:TROPHY DENTAL PA
Entity Type:Organization
Organization Name:TROPHY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:
Authorized Official - First Name:N DEBBIE
Authorized Official - Middle Name:NGUYEN
Authorized Official - Last Name:SUDBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-854-0360
Mailing Address - Street 1:301 TROPHY LAKE DR
Mailing Address - Street 2:STE 120
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262
Mailing Address - Country:US
Mailing Address - Phone:817-854-0360
Mailing Address - Fax:817-490-9029
Practice Address - Street 1:301 TROPHY LAKE DR
Practice Address - Street 2:STE 120
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262
Practice Address - Country:US
Practice Address - Phone:817-854-0360
Practice Address - Fax:817-490-9029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18141122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty